With the rapid advancement of technology, your corps should be utilizing and benefiting from online membership applications on your current website. All it takes is a simple line of text added to your website such as, "Apply Online" and link it to the secure URL we provide. EMS WebInfo's developers can create an online application specific to your ambulance corps. We can customize fields or text to fit your organization's individual needs. People of your community that are interested in membership can fill out the online application, and it will be forwarded directly to your e-mail inbox. If you would like to learn more about adding this feature, please click "Learn More" beneath the Sample Online Membership Application.

Sample Online Membership Application.(Your Organization's Name.)

* Indicates required field

First Name *

Last Name *

Sex *

MaleFemale

Date *

Date of Birth *

Soc Sec # *

Street Address *

City *

State *

Zip Code *

Mobile Phone *

Home Phone *

Email *

Occupation *

Employer *

School You Are Attending *

Current Status *

Grad Date *

Emergency Contact *

Relationship *

phone *

If You Have Served On An Ambulance Corps, Which One? *

Years Exp. *

Last Served *

6 Digit EMS # *

All prospective members must undergo a physical examination by an authorized doctor to determine the member’s physical and mental fitness for the position. If you currently have or have had any physical or mental illness, it may affect your performance as an EMT. If you have or have had any physical or mental illness, you must supply our corps physician with a release from your caring physician at the time of your physical examination stating that you can perform the duties as an EMT. Please Initial *

I understand that by signing this application, a criminal background check will be arranged by the training academy to verify my background. A criminal record will most likely prohibit an applicant from performing the hospital observation requirement of EMT training and from taking the NJ State certification examination. Without either, the applicant will not be eligible for state certification and the pending membership to this ambulance corps will be terminated. Please Initial *

Have you ever been convicted of any crime, or any offense other than a motor vehicle violation? *

YesNo

If Yes, Please State The Particulars *

Valid NJ Drivers License *

Expires *

Please List Any Resrictions Your Drivers License *

Has your driving privilege ever been denied, revoked, or suspended in this or any other state? *

YesNo

If yes, state particulars: *

I hereby apply for membership in the (Your Name) Ambulance Corps, Inc. If accepted, I promise to abide by the Rules Regulations, of (Your Corps). I understand that this application does not constitute acceptance of membership, but my acceptance will be subject to a review of the information I have provided here and any information resulting from my physical, driving and background investigations. I declare that I know the contents of this application, and certify the contents herein to be true. I fully understand that any misstatement or misrepresentation of fact, and/or the withholding of any information whatsoever may result in the denial of this application or dismissal from the (Your Corps). Please Initial *

I further understand and agree that it is my continuing obligation if accepted as a member to inform the Chief of any occurrences during my membership which would affect or change the answers to the above questions. Please Initial *

I also understand that I will be held responsible to return any equipment or supplies that will be provided for my use upon the termination of my membership or if it is requested for any other reasons. If this equipment or supplies are not returned I promise to pay the replacement value invoiced by (Your Corps). *

All members must be certified by the State of New Jersey as an EMT. Certification can be granted through an act of reciprocity or through and an accredited NJ EMT training facility. To attend such a training facility for the EMT Training Program, the student: Must be 16 years of age at the time of registration for the EMT training class. Must be able to perform at the physical and mental requirements stipulated in the Functional Position Description for the Emergency Medical Technician. Be in good physical condition and be able to lift. Must be able to hear, read, write, communicate, and interpret instructions in the English language. (All text materials are written at the 10th grade level). Must have access to a computer. Must authorize a FERPA (Family Educational Rights and Privacy Act) form that enables communications to take place between (Your Corps) and the training facility to determine the student’s progress and any issues that will require further action/s. Must participate in 10 hours clinical observation at a local hospital. Please be advised, for hospital observation time, the student will be required to provide proof of the following documentation: Criminal history check. Health Insurance - Personal Workman’s Compensation. Mantoux Test. Disease immunity vaccinations or declinations for: Hepatitis B, Flu, MMR, TDAP and Varicella. Please Initial *

When the (corp name) receives this application we will review it, and if you qualify, we will schedule a meeting to further discuss the possibility of becoming a member. This document will need to be signed in person at the time of our meeting. If you are a minor, a parent or guardian will have to attend the meeting with you. *

Print Name *

This will be signed when you meet with the GRVAC.

Signature *

Date *

Parent Consent Form for Applicants who are Minors. If the applicant is younger than 18 years, a parent or guardian must accompany the applicant to a meeting with members of (Corp name) and authorize this Membership Application. I / We hereby grant permission for our son / daughter to participate in (Corp Name). Permission includes but is not limited to all training, participation in all duties, functions and activities required by their membership classification. *